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JAIN ENT HOSPITAL

ICU

CLABSI central line associated blood stream infection


SR
NO.

DATE

NAME OF
PATIENT

IP.N
O

SIGN
/SYMPTOM

SAMPI
E
TAKEN

REPORT+
VE OR-VE

ACTIO
N
SIGNATU
TAKEN RE

REMARKS

SSI-surgical site infection


SR
NO
.

DATE

[Type text]

NAME OF
PATIENT

IP NO.

SIGN/SYMPT
OM

SAMP
IE
TAKEN

REPOR+V
E OR-VE

ACTIO
N
SIGNATU
TAKEN RE

REMARKS

JAIN ENT HOSPITAL

ICU

RETURN TO ICU WITHIN 72 HOURS


S
R
NO
.

DAT
E

NAME OF
PATIENT

DAT
E

NAME AND
ID
OF STAFF
INVOLVED

RETURN FROM
WARD/DISCHA
RGE

IP NO.

REASO
N

ACTION
TAKEN

SIGNATU
RE

REMARKS

INCIDENCE OF B LOOD AND BODY FLUIDS SPILL


S
R
NO
.

[Type text]

INCIDENCE
/BLOOD BODY
FLUID

REASON

ACTIO
N
TAKEN

SIGNATU
RE

INFO TO
ICN-SIGN

REMARKS

JAIN ENT HOSPITAL

ICU

S.N
O

DAT
E

PT
ID

S.N

DAT
E

PT
ID

[Type text]

NAME

NEAR MISSES CLINICAL AND FACILITY RELATED


DEPARTME
NT
EVENT
RESULT
ACTION

PT NAME

DEPARTME
NT

SENTINAL EVENT
IMPAIRME
EVENT
NT

INFOM
ED

INFORME
D

ACTION

SIGN

REMARKS

JAIN ENT HOSPITAL

ICU

ADVERSE DRUG EVENT

SN

DAT
E

PT.I
D

PT
NAM
E

PT.I
D

PT
NAM
E

DEPARTME
NT

CAUS
ED BY

EFFEC
T

INFORM
ED TO
NAME
&TIME

ACTION
TAKEN

NAME&SIG
N

INFOM
ED BY
NAME

ACTION
TAKEN

REMARKS

MEDICATION ERROR
SN

DAT
E

[Type text]

DEPARTME
NT

ERRO
R

EFFE
CT

INFOME
DD TO

REMARKS

JAIN ENT HOSPITAL

ICU

PATIENT FALL
S
N

SR
NO.

[Type text]

DATE

DAT
E

PT
ID

PT NAME

PATIO
NT
NAME

DEPARTMENT

INJURY

REASON

INFOMED
BY
NAME&TI
ME

INCIDENCE OF HEMATOMA AT PUNCTURE SITE


REASON
FOR THE
SIGNATUR
FORMATIOE OF
TYPE OF
N OF
NURSING
DEPARTME PROCEDURE
HAEMATO STAFF/
PATIENT ID NT
UNDERTAKEN
MA
TECHNICIANS
MINOR&MAJOR

ACTIO
N
NAME
TAKEN &SIGN

INFO
TO

REMARKS

JAIN ENT HOSPITAL

ICU

S
R
NO
.

S
NO
.

DATE

DATE

[Type text]

PATIE
NT
NAME

NAME
OF
STAFF

PATIENT
ID

PATIENT
ID

INCIDENCE OF ACCCIDENTAL REMOVAL OF TUBINGS AND CATHETERS


DATE TIME
DATE &TIME
REASON
WHEN PATIENT
WHEN
FOR
WAS
CATHETER/T
ACCIDANTAL
CATHETERISED/T UBE WAS
REMOVAL OF
DEPARTME UBE WAS
ACCIDENTALL CATHETER/T
SIGN/NUR/ST
NT
INSERTED
Y REMOVED
UBE
AFF

DEPARTME
NT

INCIDENTS OF NEEDLE STICK INJURY


REASON FOR
ACQUIRING THE
ACTION
INJURY
TAKEN
SIGNATURE

BLD TEST
DETAILS

REMARKS

REMARKS

JAIN ENT HOSPITAL

ICU

INCIDENCE OF BED SORES AFFTER ADMISSION


S
NO
.

NAME
OF
PATIEN
T

[Type text]

PATIE
NT ID

DATE OF
ADMISSI
ON

PATIENT
CONDITION
ON
ADMISSION

DIAGNOSIS

DETAILS
NURSING
CARE

DELAY IN
DAIGNOSIS

REASON FOR
BED SORE

JAIN ENT HOSPITAL

ICU

FUMIGATION RECORD

DATE

[Type text]

AREA

DON
E BY

TIME

CULTURE TAKE
BY

DETAILS OF
CULTURE

REPORT

INFORMED
TO

ACTION

RE